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3.1 Health Records
Health Records As Legal Documents The health record is a legal document. A legible, complete, and up-to-date health record not only facilitates treatment but is also invaluable for malpractice cases. If the health record shows that symptoms were observed but were reasonably ruled out as not being significant or relevant, a plaintiff’s case weakens, even though differences of opinion may exist regarding the preferred course of treatment, and even if injury resulted. A poorly kept health record, on the other hand, can make even a non-meritorious claim impossible to defend. A health record that does not have radiographs, has missing pages, or contains incomplete notes adds strength to the plaintiff’s case. If the health record has been “doctored” by insertion of chart entries subsequent to the claim, a malpractice case becomes very difficult to defend. Health Record Confidentiality Disclosure of a health record must be made only with the patient’s written permission to a person the patient has designated, such as the patient’s attorney or physician. Case law and subsequent legislation have consistently supported the patient’s right to confidentiality. Under the law, all patient communication with the dentist must be kept confidential unless disclosure is specifically authorized by the patient. The information in health records is considered the property of both the patient and the clinic, but the physical records themselves belong to the clinic. Patients or their agents are entitled to a complete copy of the records, but clinics may charge a reasonable copying fee before releasing the records. Other parties requesting patient records (including licensing or regulatory agencies, credentialing panels, public health agencies, spouses, and employers) must first obtain the patient’s written permission, or, if the patient is a minor, the permission of the parent, guardian, or other adult who has legal authority to provide consent for medical treatment. Often, government agencies have specific statutory authority to obtain personal health information. If that is the case, the information may be disclosed to the government agency without the authorization of the patient, the parent or guardian, or other adult who has legal authority to provide consent for medical treatment. Abbreviations and Terminology Click
here for information on terminology and abbreviations to use
in health records.
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